Provider Demographics
NPI:1619944485
Name:KELLY, ROBERT HART (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:HART
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:929 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-336-3432
Mailing Address - Fax:817-336-5821
Practice Address - Street 1:929 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-336-3432
Practice Address - Fax:817-336-5821
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9658207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114728203Medicaid
TX00FK84Medicare PIN
C17793Medicare UPIN